Theme: Student wellbeing |
Variations of subjective and physiological stress and clinical reasoning according to extrinsic and intrinsic stressors. | ||||||
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The effect of acute stress on medical clinical performance is equivocal. Both enhancements and impairments have been reported, often as a function of the intensity of response to stress. According to the literature, peripheral or extrinsic stressors (ES) and task-contingent or intrinsic stressors (IS) can be distinguished within a stressful situation.
The objective of this study was to assess the impact of these different kinds of stressors on medical clinical performance.
A uni and multivariate analysis of variance was performed on stress and performance measures according to time, sex, patient's attitude (aggressiveness/pleasant), clinical severity of the cas (high/low) and cognitive difficulty of the case (analogical scale).
Univariate analysis. Stress measures.
Univariate anaysis. Performance measures
Multivariate analysis
Table's cells display 1) the nature of the effect (+: increase; -: decrease) and 2) p-values according to a multivariate analysis of variance.
Orange : stress measures. Blue : clinical performance measures. Green : clinical reasoning measures
VAS: visual analogical scale. STAI: Spielberger Trait Anxiery Inventory. C_A: Tomaka’s cognitive appraisal (challenge/threat). CORT: salivary cortisol. CL_A: clinical abilities (taking history and physical examination). CO_S: communication skills. D_A: diagnostic accuracy. PAS: positive argumentation score. DAS: differential argumentation score.
VAS |
STAI |
C_A |
CORT |
CL_A |
CO_S |
D_A |
PAS |
DAS |
|
Time |
- /.001 |
- / .001 |
NS |
- /.001 |
NS |
NS |
NS |
NS |
NS |
Sex |
NS |
- / .05 |
NS |
NS |
NS |
- / .03 |
NS |
NS |
NS |
Cognitive difficulty |
+ / .001 |
+ / .001 |
+ / .001 |
NS |
NS |
- / 0.07 |
- / .001 |
- / .001 |
- / .02 |
Clinical severity (CS) |
NS |
NS |
+ / .08 |
NS |
NS |
NS |
+ / .05 |
NS |
+ / 0.3 |
Aggressiveness (A) |
NS |
+ / .03 |
NS |
NS |
+ / .001 |
+ / .001 |
NS |
NS |
NS |
CS*A (interaction) |
NS |
NS |
NS |
NS |
.001 |
.001 |
NS |
NS |
NS |
A prospective, randomized, cross over study was undertaken with 3rd year medical students conducting two medical consultations with simulated patients. As potential IS, the cognitive difficulty and the severity of the disease were studied. Contrary to severity, cognitive difficulty was not controlled, but measured in all students after each consultation on an analogical scale ranging from 0 to 100 (extremely simple-extremely difficult) . As potential ES, the patient’s aggressiveness was studied. Students were randomly assigned to four groups (cf. table above), according to the presence and the order of ES and IS during the 1st and 2nd consultations. Subjective and physiological stress responses were assessed before and after each consultation. The students’ communications skills, diagnostic accuracy and diagnostic argumentation were assessed as separate dimensions of the clinical examination.
Groups |
Consultation 1 |
Consultation 2 |
1 |
High severity - aggressive patient |
Low severity – pleasant patient |
2 |
Low severity – pleasant patient |
High severity - aggressive patient |
3 |
High severity – pleasant patient |
Low severity – aggressive patient |
4 |
Low severity – aggressive patient |
High severity – pleasant patient |
Cognitive difficulty confirmed its ability to produce stress and was significantly associated with a decrease in diagnostic accuracy and in positive and differential argumentation. A high severity of the disease didn’t induce stress but significantly improved diagnostic accuracy and differential argumentation. Aggressiveness improved clinical abilities and communication skills though it significantly produced subjective stress (increased STAI).
The high level of salivary cortisols prior to the two consultations suggests that all students were highly stressed at the beginning of the study despite the fact that they had already carried out two consultations within the hour before entering the study. The strong effect of time inducing a quick decrease in all measures of stress following the two study scenarios suggests that the main factor of stress in this study may have been the novelty of the task. Indeed, it was the first time that this cohort of students performed clinical consultations with standardized patients
As medical educators, we must be careful in analyzing the differences in clinical performance among students exposed to different kinds of stressors. We also need to pay attention to the cognitive difficulty of the task administered and should help them coping with the stress induced during feed-back sessions or introducing stress coping lessons in the curriculum.
The effect of the stressful components added to the clinical task being performedon stress and clinical performance is not unique and is highly dependent of their nature.
Professor Jean-Michel Rogez, Dean of the Nantes University Medical School, for his moral and logistic support
The following researchers in health professional education for their valuable scientific revisions: Dominique Piquette, Carilynne Yarascavitch, Walter Tavares.